74 patients with a concurrent unstable syndesmotic injury with an external rotation-type ankle fracture were randomized to reduction of the syndesmosis using either a reduction clamp or through manual manipulation by the surgeon. Patients were assessed for radiographic outcome and clinical outcome over the first year after surgery. Result demonstrated that, although clamp reduction led to significantly reduced tibiofibular clear space and greater tibiofibular overlap compared to manual reduction, the rate of malreduction did not significantly differ between groups. Additionally, there were no significant differences in postoperative clinical outcome between groups, including pain, function, and ankle range of motion.